Case Presentation: This is a 60 year old woman with systolic heart failure, and giant left atrium (atriomegaly) resulting from past history of rheumatic heart disease, presenting to the emergency department with clinical picture consistent with pneumonia and subsequent shock. Bronchoscopy done and found total left main stem bronchus obstruction by the left atriomegaly. Shock later on was confirmed to be cardiogenic without a septic component. Impression was that the pneumonia has exacerbated the preexisting heart failure; which in turn caused further enlargement of the left atrium to the extent of obstructing the bronchus.
Discussion: Four somewhat similar cases of cardiomegaly induced near total airway obstruction have been reported previously. First case described a 53 years old man with severe mitral regurgitation form mitral valve prolapse, who developed total distal left main stem obstruction at the secondary carina; by severe extrinsic compression by giant left atrium (GLA) (1). The second case is almost identical to our case, it described a 67 years old woman with past history of rheumatic heart disease; presenting with severe extrinsic compression of the right middle lobe bronchus by a giant left atrium (GLA); after a pneumonia (1). Our case however, involved the left main bronchus mainly and the right middle lobe to a lesser extent. The third case described an infant with massive cardiomegaly due to dilated cardiomyopathy; who developed severe external compression of the left main stem bronchus and obstruction by an enlarged left atrium (4). The last case described pulmonary atelectasis as the result of severe compression of the left main bronchus by an enlarged left atrium; in a patient with both mitral valve disease and aortic insufficiency (King-Landau-Rivero-Syndrome) (5). So, one case of rheumatic heart disease with severe airway compression and obstruction have been reported previously in the literature, and obstruction was right sided in contrast with our case which was bilateral.
Conclusions: This case the first of its kind to report left main stem bronchus total obstruction as a complication of rheumatic heart disease.
